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Iowa Medicaid Care Management Programs

Care Management

The IME programs that focus on the top 5% of the highest cost and highest risk members representing 48 percent of all acute care costs. These Iowa Medicaid members account for 90 percent of all hospital readmissions within 30 days of discharge, 51% of all preventable hospitalizations, 75 percent of all inpatient costs, and 31 percent have a chronic disease. The over-arching characteristic of the top 5 percent outlier population is uncoordinated care. Uncoordinated care includes over utilization of services in high cost settings such as using emergency room for non-emergent reasons, under-utilization of primary and preventive care, and the absence of a medical home or primary care provider. The top 5 percent include members with chronic diseases as well as high risk maternity members. The goals of our programs are to support the provider's plan of care and to coordinate services so Medicaid members can achieve the best possible outcomes.

Disease Management

The Iowa Medicaid Disease Management program focuses on high-risk, high-cost adult and child members with multiple chronic conditions. Registered Nurses/Health Coaches engage members by assessing their level of readiness to participate in their healthcare and by linking members to a primary care physician or medical home if the member has none. Once a primary care physician is established, the health coach works to support the treating practitioner by reinforcing treatment plans, arranging transportation to appointments, finding available resources for members, and providing the member with self-care education as well as testing and appointment reminders.

Maternity

The Iowa Medicaid Maternity program includes a telephone outreach program to provide support, education and counseling to women who have had previous maternity complications or medical conditions who may be at high risk with their current pregnancy.

Lock-In

Members who use Medicaid services or items at a frequency or in an amount that is considered overuse of services may be restricted ("locked in)" to receive services from designated providers. The purpose of the lock-in program is to promote high quality health care and to prevent harmful practices such as duplication of medical services, drug abuse or polypharmacy use, and or emergency room use for non-emergent reasons. If a member is placed in Lock-in, they are restricted to one pharmacy, one hospital, and one primary care physician to assist in coordination of all Medicaid services including approval of medications and referrals to other providers as deemed necessary.